Large Soft Tissue Research Articles

The clinical application of arterialized venous flaps in repairing large area of soft tissue defects of extremities

Background The reconstruction of microsurgery emphasizes the low morbidity of donor sites. The arterialized venous flaps (AVFs) are tissue flaps harvested without conventional vascular pedicles. However, reports of high necrosis rates and poor understanding of physiology hindered the application of many surgeons in clinical practice. Recently, experimental and clinical studies have demonstrated the feasibility and relative reliability of various AVF techniques. This study aims to report the clinical results of the arterialized venous free flaps in reconstructing soft tissue defects of limbs and propose methods to improve flap perfusion, extending the indications for using the flaps based on the authors’ clinical experiences. Methods We retrospectively reviewed the records of 16 patients that underwent arterialized venous free flaps for limb wound reconstruction from January 2019 to June 2021. Following the venous network on the calf’s tibial side, large venous flaps can be designed. Results Of the 16 cases, 14 (87.50%) cases (including 8 cases significantly congested with tension blisters) showed complete survival, and 2 (12.5%) cases, which had only one vein performed anastomosis of the efferent vein according to the vascularity of the recipient bed, showed partial necrosis. In all cases, no infection or other specific complications occurred in the donor areas. Conclusion The rate of congestion and necrosis of arterialized venous flaps is still challenging, but it will be suitable for large soft tissue defects of limbs in the future.

LBODP072 Squamous Cell Carcinoma Or Fungal Infection? An Unusual Presentation Of Anterior Hypopituitarism

Abstract Introduction Intracranial squamous cell carcinomas are rare tumours with a poor prognosis. Lack of specific imaging characteristics mandates a high index of clinical suspicion and ultimately histopathological confirmation. Chronic invasive fungal rhinosinusitis (CIFRS) is often difficult to distinguish from Sino nasal squamous cell carcinomas (SNSCC) in clinical practice. Our case draws attention to the fact that biopsy results are necessary in discriminating between the two entities, due to the diagnostic conundrum in context of Anterior Hypopituitarism. Case detailsWe report a case of 78-year-old lady who presented with a 3-month history of increasing headache, lethargy and confusion. There was no change in urinary habit. On examination she had right sided ptosis and restricted eye movements with a reported 4-week duration. Primary care physicians referred her for ophthalmic assessment. Past medical history was significant for absent vision in the affected eye due to Ischaemic optic neuropathy since 2018. A CT Angiogram was organised which revealed a large soft tissue mass that could not be differentiated from the optic chiasma. Differentials included chondrosarcoma, chordoma, invasive pituitary macroadenoma and skull base Plasmacytoma. Subsequent MRI imaging suggested appearances could be consistent with aggressive fungal sinusitis. Endocrine investigations showed partial anterior hypopituitarism. ManagementEmpiric treatment was started with Intravenous anti-fungals and steroids, alongside appropriate pituitary hormone replacement. Her case was discussed in the Skull Base Multi-disciplinary Team (MDT) meeting. She was then transferred to the regional tertiary centre for surgical intervention, where she underwent debridement of the Ethmoid sinus, Sphenoid Sinus and Anterior base of skull for presumed chronic invasive fungal sinusitis. Post-operative imaging displayed satisfactory debulking of the central skull base tumour. Histopathology from sphenoid sinus reported invasive squamous cell carcinoma. The post-operative imaging and histopathology results were discussed in the regional MDT and considering the advanced stage a decision was made for best supportive care. Within 2 months neurological symptoms progressed and further imaging demonstrated radiological tumour progression. Discussion Sinonasal Squamous cell carcinoma (SNSCC) is a rare tumour and thus pose difficulty in detection. Presentation usually occurs at an advanced stage since initial symptoms are nonspecific and the tumour remains indolent for many months to years. There is limited evidence in relation to detection and follow up of these cases. Clinical presentation and radiological appearance can be varied. This case highlights the need for histological confirmation of the diagnosis to guide appropriate treatment pathways and ensure compassionate, appropriate care. Presentation: No date and time listed

Ilizarov Bone Transfer for Treatment of Large Tibial Bone Defects: Clinical Results and Management of Complications

The purpose of this study is to present our clinical experience using the Ilizarov bone transfer technique and free-flap technique in the reconstruction of large tibial bone and soft tissue defects, including an evaluation of both the management of postoperative complications and long-term outcomes. From January 2010 to May 2020, 72 patients with tibia bone and soft tissue defects were retrospectively evaluated. Either an anterolateral thigh perforator flaps (ALTP) or latissimus dorsi musculocutaneous flaps (LD), solely or in combination, were used to cover soft tissue defects. Once the flap was stabilized, an Ilizarov external fixator was applied to the limb. Follow-up was postoperatively performed at 1, 3, 6, 9, and 12 months. Postoperatively, there were two cases of total and five of partial flap necrosis, and two cases of subcutaneous ulcers, which were caused by vascular crisis, infection, and hematoma, respectively. All the patients underwent Ilizarov external fixator surgery after flap recovery. A total of 16 complications occurred, including 3 cases of simple needle tract infection (antibiotic treatment) and 13 cases of complications requiring reoperation. A correlation factor analysis revealed that the main factors affecting the healing time were the defect length and operative complications. All patients with complications treated with the vascularized iliac flap eventually healed completely. The Ilizarov method used together with an ALTP, LD, or a combination thereof yields good clinical results for repairing large bone and soft tissue defects of the tibia, thus reducing the incidence of amputations. However, longer treatment times may be involved, and postoperative complications can occur. The vascularized iliac flap may be a suitable choice for the treatment of postoperative complications of this type of Ilizarov bone transport.

Upper Limb Salvage Surgery Due to Explosion Using Vacuum-Assisted Closure: A Case Report

High trauma injuries of the forearm frequently present with complex bone and soft tissue defects. Early repair is required to retrieve the extremity and restore its function, As the advance of surgical repair and reconstruction technology, limbs damaged by high energy trauma that might have needed to be amputated in the past can now be saved by surgical reconstruction
 This is a case report of 36 year old man with left upper limb injury after high energy explosion trauma where a large soft tissue defect of the forearm with exposure of the vital structures and fracture of the ulna and radius and the fracture of radius and ulna were fixed by Elastic Nail to maintain their alignments and length, and put a cerclage on the fracture site of the radius to hold a fragment. The large soft tissue was reconstructed by a primary tendon and muscle repair, with vacuum assisted closure followed by split thickness skin graft. And at 6 Weaks physıotherapy was started wıth dynamıc hand splınt by slıgthly flexıng the fıngers
 The application of VAC as temporary coverage of large tissue defects in upper limbs supports wound conditioning and facilitates the definitive wound closure.

Pembrolizumab leading to complete resolution of non-small cell lung cancer and microsatellite instability stable colon adenocarcinoma; two birds one stone

Introduction: Staging of non-small cell lung cancer is crucial in predicting patient prognosis and more importantly, determining cancer management. In patients without driver mutations, PD-L1 tumor proportion score evaluation becomes vital in dictating treatment, as immunotherapy can be recommended. These agents have been shown to lead to excellent outcomes, even in patients with late-stage disease. Case Report: A 69-year-old male with a history of chronic obstructive pulmonary disease (COPD) presented with worsening dyspnea found to have lung collapse from a large hilar soft tissue mass causing obstruction of the left mainstem bronchus. After malignancy workup, the patient was diagnosed with non-small cell lung cancer clinically staged as IIIB. An incidental finding of microsatellite instability colon cancer was also found during workup. Pembrolizumab treatment was initiated and led to near resolution of both tumors. Conclusion: Stage IIIB non-small cell lung cancer has an overall poor prognosis. Biomarker testing in our case prior to starting concurrent chemoradiation revealed the malignancy to have a 100% tumor proportion score for PD-L1, the fundamental reason why our patient’s treatment was successful. Based on our findings, we advocate for all patients with non-small cell lung cancer regardless of stage to undergo biomarker testing prior to therapy initiation. Furthermore, the resolution of PD-L1 negative microsatellite instability stable colon cancer after pembrolizumab therapy supports further investigation of the utility and mechanism of PD-1/PD-L1-based therapy in PD-L1 negative colon cancer.

INTRAMEDULLARY GAS: A NEW FEATURE THAT PORTENDS A POOR PROGNOSIS IN COVID-19?

INTRAMEDULLARY GAS: A NEW FEATURE THAT PORTENDS A POOR PROGNOSIS IN COVID-19?

A Modified Scapular-Parascapular Flap Design for Optimal Coverage of the Residual Limb.

Large soft tissue defects associated with major limb amputation pose a challenge to the reconstructive surgeon due to the 3-dimensional contour of the residual limb and the need to withstand the unnatural shear forces imparted by prosthetic sockets. Fasciocutaneous flaps based on the circumflex scapular system have proven useful for residual limb coverage due to the durability of the tissue provided, the absence of functional morbidity, and the ease of reelevation. A modified, bilobed flap design that incorporates large Burrow triangles into each limb serves to leverage the perforasome anatomy of the posterior trunk to provide maximal 3-dimensional coverage and favorable flap geometry while also facilitating donor site closure. A retrospective medical record review was performed for all patients who underwent reconstruction of a residual limb after major amputation using the modified, bilobed scapular-parascapular free flap design at Walter Reed National Military Medical Center between 2018 and 2021. A computer-based application was used to calculate flap area and dimensions based on photographs of preoperative and intraoperative markings. Six patients with varying amputation levels (2 transtibial, 1 transfemoral, 1 hip-disarticulation, 1 hemipelvectomy, 1 transradial) underwent soft tissue coverage using the modified flap design. Mean flap area was 318.4 cm 2 with 51.1 cm 2 attributable to the modified design. This represents a 16% increase over a conventional bilobed design. There were no partial or complete flap failures. The modified scapular-parascapular flap design enables harvest of a larger and more versatile fasciocutaneous flap with geometry that is well suited for coverage of the residual limb.

S3663 Refractory Hypoglycemia Induced by a Gastrointestinal Stromal Tumor Secreting Insulin-Like Growth Factor-2

Introduction: Non-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome that leads to the release of insulin-like growth factor-2 (IGF-2). It is commonly associated with tumors of mesenchymal origin like gastrointestinal stromal tumors (GIST). Case Description/Methods: A 62-year-old male, with a past medical history of recently diagnosed GIST was started on imatinib but stopped taking it one month ago pending surgical evaluation, presents with altered mental status due to severe hypoglycemia. The patient had no prior history of diabetes or adrenal insufficiency. The patient's repetitive finger sticks glucose remained persistently low even after good oral intake and two D50 pushes. Urine toxicology and drug screen for sulfonylureas were negative. Laboratory investigations showed reduced levels of insulin, C-peptide, and insulin-like growth factor-1 (IGF-1), but his IGF-2 was increased. Endocrinology was consulted for refractory hypoglycemia; recommended to start D10 fluids in the setting of resistant low blood glucose and start octreotide and steroids. Insulinoma was unlikely as insulin and C-peptides were low. CT chest/abdomen/pelvis shows grossly unchanged gastric GIST, measuring 25 × 19.6 × 11.4 cm with no evidence of metastatic disease in the abdomen or pelvis (Figure 1A). Esophagogastroduodenoscopy (EGD) demonstrated large, bilobed subepithelial mass measuring 10-15 cm with an area of ulceration within the mass (Figure 1B) followed up with Endoscopic ultrasound (EUS) demonstrating subepithelial lesion was found likely arising from the fundus, lesser curve and body of the stomach, layer of origin could not be determined on due to the large size of the mass (Figure 1C). Oncology was consulted for further management of malignancy; imatinib was resumed and referred for surgical evaluation for tumor removal. Discussion: IGF-II acts as an autocrine growth factor in tumor cells therefore, it is highly likely that IGF-II will be high in case of high tumor bulk and making them at high risk of developing NICTH. In patients diagnosed with GIST with hypoglycemic symptoms, we should consider IGF-II secreting GIST in addition to insulinoma especially in bulky tumors.Figure 1.: A: CT scan abdomen/pelvis with contrast showing large soft tissue density mass inseparable from the lesser curvature of the stomach marked with asterisk. B: EGD findings consistent with a large, bilobed subepithelial mass measuring 10-15 cm with an area of ulceration within the mass (seen best on retroflexion) was found on the lesser curvature of the stomach along the anterior wall of the stomach. C: Endoscopic US findings showed A 43.0 mm × 77.8 mm subepithelial lesion was found likely arising from the fundus, lesser curve and body of the stomach s/p FNB × 4. The lesion was hypoechoic and had some cystic spaces within it in some areas. Sonographically, the lesion appeared to originate from the stomach, but the wall layers could not be determined due to the large size of the mass.

Utilizing Nasolabial Local Flap in Management Proliferative MRONJ: A Case Report

This case report demonstrates utilization of nasolabial flap for reconstruction a large soft tissue defect associated with osteo-necrotic anterior mandible in highly infiltrative aggressive MRONJ. Immediately after the operation, healing of the lesion was optimized and patient become symptom free

Image-guided transthoracic transpedicular microdiscectomy for a giant thoracic disc herniation: patient series

BACKGROUNDThis case series reports on five consecutive patients who underwent image-guided transpedicular transthoracic microdiscectomy. The authors retrospectively reviewed five patients who had undergone Stealth image-guided transpedicular transthoracic microdiscectomy between 2015 and 2021.OBSERVATIONSImage guidance with O-arm verified critical anatomical landmarks in the setting of large central calcified and/or soft tissue disc prolapse. This allowed limited rib head resection, pedicle removal, and corpectomy to give adequate access and not require interbody fusion. The authors performed a partial posterior corpectomy anterior to the affected disc prolapse and microsurgical delivery of the affected disc anteriorly into the corpectomy cave away from the thecal sac. Electronic and radiographic records were analyzed at their initial presentation and at follow-up. The median patient age was 51 years (range, 44–56 years), with 80% of the patients being males. Four of five patients had significant improvement of their presenting clinical symptoms. One patient had a complicated postoperative recovery with a pneumothorax and subsequent bilateral pneumonia requiring intensive care. Another patient developed delayed postoperative worsening of paraparesis.LESSONSThe use of Stealth image guidance with O-arm for transthoracic microdiscectomy for complex calcified thoracic disc herniation is an effective operative technical adjunct to verify anatomical landmarks and limit the microsurgical procedure.

Isolated Skull Metastasis as first presentation of possible primary from Lung

Skull or scalp metastasis is commonly seen in carcinoma of breast, prostate, kidneys and lungs. Here we report a case of 80-year-old male who presented with scalp swelling for treatment. High resonance ultrasonography (HRUS) and contrast-enhanced computed tomography (CECT) of brain showed large soft tissue lesion on right occipito-parietal region with erosion of underlying bone, suggestive of neoplastic etiology. Subsequently, on further workup, his CT thorax showed lesion in right hilar and lower lobe of right lung with mediastinal lymph nodes. Patient underwent excision of the right occipito-parietal lesion which on histopathology was reported as epithelial malignancy, favoring metastatic moderately differentiated squamous cell carcinoma. This case is reported here to emphasize the importance of good clinical workup to rule out metastatic lesions which might be the initial presentation of an unknown primary at other site.

Free superficial circumflex iliac artery flap combined with deep inferior epigastric perforator flap for repair of large soft tissue defects of upper extremities

To investigate the effectiveness of free superficial circumflex iliac artery flap (SCIP) combined with deep inferior epigastric perforator flap (DIEP) in repairing large soft tissue defects of upper extremities. Between February 2017 and January 2021, free SCIP combined with DIEP was used to repair 15 patients with large soft tissue defects of upper extremities. There were 12 males and 3 females, aged from 34 to 52 years, with a median age of 41 years. The causes of injury were mechanical injury in 11 cases and traffic accident injury in 4 cases. There were 9 cases of circular skin defect in the forearm and 6 cases of skin defect around the upper arm and elbow joint, with the defect in size of 15.5 cm×10.5 cm to 26.5 cm×15.5 cm, accompanied by exposure of deep tissues such as tendons and bones. There were 7 cases with open fractures and 8 cases with vascular and nerve injuries. The time from injury to operation ranged from 7 to 14 days, with an average of 7.5 days. The flaps in size of 16.0 cm×11.0 cm to 27.0 cm×16.0 cm were harvested; the thickness of the flaps was 0.8-1.3 cm, and the excess fat tissue was removed under the microscope after harvesting. The length of proximal vascular pedicle was 5.0-7.0 cm, and of distal vascular pedicle was 3.0-5.0 cm. The donor site was closed and sutured directly, and the navel was reconstructed. The flaps survived successfully in 14 cases, and the arterial crisis occurred in 1 case at 10 hours after operation, and the flap survived after surgical exploration. All the wounds in the donor and recipient sites healed by first intention. All 15 patients were followed up 3-14 months, with an average of 10.5 months. The appearance, elasticity, and texture of flap were good without obvious bloat, contracture, or adhesion. The donor site healed well, no abdominal wall hernia was found, and the appearance of reconstructed navel was good, only linear scar left. At last follow-up, 12 cases were evaluated as excellent and 3 cases were good according to the evaluation criteria of flap function of the Chinese Medical Association Microsurgery Branch. The sensation recovered to in 7 cases and in 8 cases. Free SCIP combined with DIEP has a large excision area and excellent skin ductility. It is an effective clinical method for repairing large soft tissue defects of upper extremities.

Variations of Extended Latissimus Dorsi Musculocutaneous Flap for Reconstruction of Large Wounds in the Extremity.

ObjectiveThe aim of the present study was to report a novel nomenclature system for extended latissimus dorsi musculocutaneous (LD) flaps. To evaluate the clinical application and surgical efficacy of the different extended LD flaps for large wounds in the extremities.MethodsFrom January 2004 to December 2018, 72 consecutive patients who received extended LD flaps were retrospectively analyzed. Patients' ages ranged from 2 to 68 years with 37 males and 35 females. All wounds were extensive in either the upper or lower limbs, while the skin defect area ranged from 18 cm × 10 cm to 37 cm × 21 cm. Forty‐one wounds were located in the calf, 18 in the foot and ankle, six in the shoulder and upper arm, four in the thigh, and three at the knee joint. Twenty‐eight patients had fractures, and six of these patients with segmental bone defects (ranging in size from 3 to 7 cm) required secondary orthopaedic procedures. Single‐ and double‐wing extended LD flaps were designed and harvested according to the shape of the wounds.ResultsThe flaps received consisted of 64 single‐wing and eight double‐wing extended LD flaps, and the mean flap harvest time was 56.2 min. The donor sites were closed primarily for all patients. Additional subcutaneous veins were anastomosed to the recipient's vessels in 14 patients. The venous crisis was noticed on the first postoperative day in four cases. Two flaps were salvaged after emergency re‐exploration, and another two patients' flaps were necrosed. In these two patients, lower limb amputation and extended LD flap on the other side were used, respectively, for the final treatment. The wounds healed well, providing reliable soft tissue coverage and good contour in the reconstructed areas. Six patients had segmental bone defects that required secondary orthopaedic procedures, two patients were repaired with vascularized iliac crest bone grafts, and another four patients were reconstructed by the Ilizarov technique. All the patients' bone defects achieved union and most patients achieved good functional recovery at the recipient site. The mean follow‐up was 15.7 months (range, 10–56 months). No significant donor site morbidities limiting patients' daily activities occurred during the follow‐up. Eight patients developed a donor site hypertrophic scar, three patients on the back, and five on the anterolateral thigh.ConclusionSingle‐ and double‐wing extended LD flaps are simple and reliable methods for large skin and soft tissue defects in the extremity, with good functional and aesthetic results.

The Great Saphenous Vein-An Underrated Recipient Vein in Free Flap Plasty for Lower Extremity Reconstruction: A Retrospective Monocenter Study.

Background Reconstruction of large soft tissue defects of the lower extremity often requires the use of free flaps. The main limiting factor and potential for complications lie in the selection of proper donor and recipient vessels for microvascular anastomosis. While the superficial veins of the lower leg are easier to dissect, they are thought to be more vulnerable to trauma and lead to a higher complication rate when using them instead of the deep accompanying veins as recipient vessels. No clear evidence exists that proves this concept. Methods We retrospectively studied the outcomes of 97 patients who underwent free flap plasty to reconstruct predominantly traumatic defects of the lower extremity at our institute. The most used flap was the gracilis muscle flap. We divided the population into three groups based on the recipient veins that were used for microvascular anastomosis and compared their outcomes. The primary outcome was the major complication rate. Results Overall flap survivability was 93.81%. The complication rates were not higher when using the great saphenous vein as a recipient vessel when comparing to utilizing the deep concomitant veins alone or the great saphenous vein in combination to the concomitant veins. Conclusions In free flap surgery of the lower extremity, the selection of the recipient veins should not be restricted to the deep accompanying veins of the main vessels. The superficial veins, especially the great saphenous vein, offer an underrated option when performing free flap reconstruction.

Reconstruction of Large Soft Tissue Defects in the Distal Lower Extremity: Free Chain-Linked Bilateral Anterolateral Thigh Perforator Flaps versus Extended Latissimus Dorsi Musculocutaneous Flaps.

Background: Reconstruction of the large soft-tissue defects in the lower extremity still constitutes a challenge for plastic surgeons. This retrospective study was conducted to compare the surgical and clinical outcomes of the chain-linked bilateral anterolateral thigh perforator flaps and extended latissimus dorsi musculocutaneous flap in the reconstruction of the large soft tissue defects of the lower extremity. Methods: From January 2012 to December 2021, 34 patients aged between 20 and 66 years received chain-linked bilateral anterolateral thigh perforator flaps (15 cases) or extended latissimus dorsi musculocutaneous flaps (19 cases) for the reconstruction of extensive soft-tissue defects in the lower extremity. The two groups were homogeneous in terms of age, etiology, comorbidities, and flap area. In addition, the intraoperative data, outcomes, complications, and long-term follow-up results were collected and analyzed. Results: The extended latissimus dorsi musculocutaneous flap group had a shorter operation time (271.8 ± 59.5 min vs. 429.6 ± 51.9 min), harvest time (58.9 ± 24.8 min vs. 152.7 ± 41.4 min), and anastomosis time (27.2 ± 10.4 min vs. 53.7 ± 8.1 min) than the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Based on patient self-assessment, the donor site temporary muscle weakness in the extended latissimus dorsi musculocutaneous flap group was significantly more than that in the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Conclusion: Both methods can repair large defects and restore the function of the injured limbs at a single stage. However, considering the operation time and flap-harvesting time, the authors recommend the extended latissimus dorsi musculocutaneous flap, especially for those who cannot tolerate a prolonged surgery.

LARGE PERIPHERAL OSSIFYING FIBROMA: CASE REPORT

Peripheral ossifying fibroma (POF) is a benign fibro-osseous lesion with progressive and slow growth, with a sessile or pedicled base, more common in women in the third or fourth decade of life. The purpose of this study is to report 2 cases of large POF. One case affected a 43-year-old woman and the other is a 35-year-old with a history of more than 6 years of evolution. Both cases presented as a large soft tissue tumor, painless and firm on palpation, on the left side of the maxilla. Imaging exams (panoramic radiography and computed tomography) showed tenuous mineralization within the pathologic mass. The lesions were removed by excisional biopsy under local anesthesia and the anatomopathologic exam confirmed the clinical suspicion of POF. Both patients continue to be followed up, with no signs of recurrence.

Concurrent Mucocele and Silent Sinus Syndrome after Orbital Fracture Repair

A 59-year-old man sustained a left medial wall-floor fracture requiring repair (Fig A). Eight years later, the patient presented with left-sided proptosis and binocular diplopia. Visual acuity was normal with no afferent pupillary defect. Extraocular movements were limited in supraduction and abduction in the left eye. Orbital computed tomography demonstrated a large soft tissue density representing a mucocele encasing the implant (Fig B). There was also opacification of the left maxillary sinus and bowing of the orbital floor consistent with silent sinus syndrome.

Fetal Disseminated Malignant Rhabdoid Tumor.

Fetal Disseminated Malignant Rhabdoid Tumor.

Procurement and Perfusion-Decellularization of Porcine Vascularized Flaps in a Customized Perfusion Bioreactor.

Large volume soft tissue defects lead to functional deficits and can greatly impact the patient's quality of life. Although surgical reconstruction can be performed using autologous free flap transfer or vascularized composite allotransplantation (VCA), such methods also have disadvantages. Issues such as donor site morbidity and tissue availability limit autologous free flap transfer, while immunosuppression is a significant limitation of VCA. Engineered tissues in reconstructive surgery using decellularization/recellularization methods represent a possible solution. Decellularized tissues are generated using methods that remove native cellular material while preserving the underlying extracellular matrix (ECM) microarchitecture. These acellular scaffolds can then be subsequently recellularized with recipient-specific cells. This protocol details the procurement and decellularization methods used to achieve acellular scaffolds in a pig model. In addition, it also provides a description of the perfusion bioreactor design and setup. The flaps include the porcine omentum, tensor fascia lata, and the radial forearm. Decellularization is performed via ex vivo perfusion of low concentration sodium dodecyl sulfate (SDS) detergent followed by DNase enzyme treatment and peracetic acid sterilization in a customized perfusion bioreactor. Successful tissue decellularization is characterized by a white-opaque appearance of flaps macroscopically. Acellular flaps show the absence of nuclei on histological staining and a significant reduction in DNA content. This protocol can be used efficiently to generate decellularized soft tissue scaffolds with preserved ECM and vascular microarchitecture. Such scaffolds can be used in subsequent recellularization studies and have the potential for clinical translation in reconstructive surgery.

Tumors of the Spine: When Can Biopsy Be Avoided?

Regarding osseous tumors of the spine, characteristic morphology is encountered in hemangioma of the vertebral body, osteoid osteoma (OO), osteochondroma, Paget's disease, and bone islands. In these cases, radiologic imaging can make a specific diagnosis and thereby avoid biopsy, especially when the radiologist has chosen the correct imaging modality to establish the diagnosis, such as thin-slice computed tomography in suspected OO. A benign lesion is suggested by a high amount of fat within the lesion, the lack of uptake of the contrast agent, and a homogeneous aspect without solid parts in a cystic tumor. Suspicion of malignancy should be raised in spinal lesions with a heterogeneous disordered matrix, distinct signal decrease in T1-weighted magnetic resonance imaging, blurred border, perilesional edema, cortex erosion, and a large soft tissue component. Biopsy is mandatory in presumed malignancy, such as any Lodwick grade II or III osteolytic lesion in the vertebral column. The radiologist plays a crucial role in determining the clinical pathway by choosing the imaging approach wisely, by narrowing the differential diagnosis list, and, when characteristic morphology is encountered, by avoiding unnecessary biopsies.